Pressure transmission and distribution

under denture bases using denture teeth

with different materials and cuspal
angulations
Mansuang Arksornnukit, DDS, MS, PhD,a Thitima
Phunthikaphadr, DDS,b and Hidekazu Takahashi, DDS, PhDc
Chulalongkorn University, Bangkok, Thailand; Tokyo Medical and
Dental University, Tokyo, Japan
Statement of problem. Pressure transmission and distribution under denture bases may be variable depending on the
different materials and cuspal angulations of denture teeth.

Purpose. The purpose of this study was to evaluate pressure transmission and distribution under impact load using
denture teeth made with different materials and cuspal angulations.

Material and methods. Three types (acrylic resin, microfilled composite resin, and ceramic) and 4 different cuspal
angulations (0 degree, 20 degree, 33 degree, and 35 degree) of denture teeth were evaluated. Pressure transmission,
distribution, and maximum pressure (n=10) were observed with pressure-sensitive sheets under an impact load. Data
were statistically analyzed with 2-way ANOVA (α=.05) to determine significant interactions between denture tooth
materials and cuspal angulations with respect to pressure transmission, followed by 1-way ANOVA (α=.05) to examine
how materials and angulations jointly affected the pressure. Two 1-way ANOVAs were performed on the acrylic resin
and ceramic denture teeth with the inclusion of 20-degree denture teeth groups. Tukey HSD and Tamhane’s post hoc
tests were used to evaluate data differences among groups.

Results. Denture tooth materials and cuspal angulations had significant interactions with respect to average pressure
(P<.001) and maximum pressure transmission (P=.007). Zero-degree denture teeth showed significantly lower aver-
age and maximum pressures than 33- and 35-degree denture teeth for all 3 denture tooth materials (P<.001). Denture
teeth with greater cuspal angulations demonstrated significantly higher average pressure transmission for all ceramic
denture teeth groups (P<.05).

Conclusions. Pressure transmission and distribution varied among denture teeth made of different materials and with
different cuspal angulations. Cusped denture teeth presented significantly higher average pressure and maximum pres-
sure transmission compared to 0-degree denture teeth. (J Prosthet Dent 2011;105:127-136)

Clinical Implications
Denture teeth made of different materials and with different cuspal
angulations showed varying amounts and patterns of pressure distri-
bution. Zero-degree denture teeth may be considered an option for
patients with atrophied residual ridges as they provide lower pres-
sure transmission compared to cusped denture teeth.

Although removable prostheses tients,1 studies have demonstrated chronic, slowly progressing, irrevers-
are provided to enable oral masti- that alveolar ridge resorption is com- ible, and cumulative process.5 The
catory function and to improve the monly observed in denture wearers.2-4 magnitude and pattern of the resorp-
quality of life for edentulous pa- The resorption of residual ridges is a tion have also shown variation.2,4 The

Financial support for this study was provided by the 100 th Anniversary of Chulalongkorn University Fund (Ratchadaphiseksomphot
Endowment Fund).

a
Associate Professor, Department of Prosthodontics, Faculty of Dentistry, Chulalongkorn University.
b
Graduate student, Department of Prosthodontics, Faculty of Dentistry, Chulalongkorn University.
c
Associate Professor and Chair, Advanced Biomaterials, Division of Oral Health Sciences, Tokyo Medical and Dental University.
Arksornnukit et al
128
cause of resorption process is com-
plex; Kordatzis et al6 have reported
that the number of edentulous years,
initial height of the mandible, and the
number of dentures used are not as-
sociated with the amount of resorp-
tion. Even though the increase in
residual ridge resorption seen in den-
ture wearers has been attributed to
pressure from prostheses,3 it was sug-
gested that a proper amount of pres-
sure within the limits of physiological
tolerance, applied in the direction of
normal forces to a particular region,
could stimulate bone apposition.7
Ortman8 considered bone resorp-
tion to be a normal process that is
balanced by bone apposition; this
process may be either physiologic or
pathologic depending on multiple
factors. If pressure from denture pros-
theses alters the blood supply of the
bone or causes inflammation to the
mucoperiosteum, bone resorption
may occur. Matsuo et al9 reported
that a pressure of 27 to 68 g/cm2
caused fibroblasts to increase intra-
cellular calcium which, in turn, initiat-
ed the alveolar bone remodeling. Berg
et al10 also suggested that, to keep
blood circulation normal, a continu-
ous mechanical pressure higher than
1.3 kPa should not be transferred to
the denture-supporting tissues. Ac-
cording to the authors of these stud-
ies, dentures should be designed and
fabricated with an emphasis on pres-
ervation of the remaining oral struc-
tures, and efforts should be made
to lower stresses to residual alveolar
ridges.
Prosthesis fabrication requires care
in each step, and one key factor is the
selection of suitable denture teeth for
each patient. Various types of poste-
rior artificial tooth forms for dentures
are commercially available.11 For some
dentists, the science of choosing arti-
ficial teeth is an automatic procedure
based on regular use of particular
materials or a philosophy acquired
in dental school or clinical practice.
Nevertheless, a more rational ap-
proach for tooth selection should be
based on the physical properties of
The Journal of Prosthetic Dentistry
dental materials and the anatomic
and physiologic requirements of the
patient.11
The task of choosing proper den-
ture teeth for dentures has resulted
in 2 primary considerations, materi-
als11,12 and the forms of the denture
teeth.13-16 Investigators have consid-
ered posterior tooth forms13-16 and
cuspal angulations,17,18 with several
studies evaluating the effectiveness
of and patient satisfaction with dif-
ferent occlusal forms of denture
teeth.15,16,18-21 Some authors reported
that patients provided with com-
plete dentures having lingualized or
anatomic posterior occlusal forms
expressed significantly higher levels
of satisfaction compared to patients
with dentures with 0-degree posterior
occlusal forms.16,19 The subject groups
in the study, however, were not strati-
fied for age, gender, degree of residual
ridge resorption, denture experience,
or previous type of denture occlusal
scheme, and the authors considered
this a weakness of the investigation.16
Diverse opinions about different
occlusal schemes with various poste-
rior tooth forms have also been intro-
duced.22-24 Cusped denture teeth are
commonly chosen by clinicians for
balanced occlusal schemes in com-
plete dentures. Boucher22 stated that
cusped teeth provide an easy oppor-
tunity to acquire bilateral (cross-arch)
balanced occlusion, which is difficult
to achieve with cuspless teeth. The
reason behind the concept of bilat-
eral balanced occlusion is to prevent
rocking movements via additional
balancing contacts on molars during
protrusive and laterotrusive move-
ments.23 Some authors suggest using
canine guidance to prevent parafunc-
tional activities in complete denture
patients.24
Investigators have previously ex-
amined residual ridge resorption in
complete denture patients with ana-
tomic, nonanatomic, and semiana-
tomic posterior teeth.25,26 The results
showed that the anatomic occlusal
group had significantly less resorption
compared to the nonanatomic group,
Volume 105 Issue 2
and less denture movement from rest
position to centric occlusion over a
5-year period. These authors25,26 sup-
ported the use of anatomic posterior
occlusion to enhance the stability and
decrease the amount of mandibular
bone resorption. In contrast, some
dentists believe that nonanatomic
posterior occlusion is the most prac-
tical and reasonable solution for all
edentulous patients, especially for pa-
tients with flat residual ridges.27
According to the authors of pre-
vious studies investigating posterior
occlusal forms of denture teeth, there
has been little focus on pressure be-
neath denture bases with different
cuspal angulations.13,17 Transmission
of masticatory forces directly to the
edentulous residual ridges should be
measured to determine whether more
or less cuspal angulation would be
preferable. Lopuck et al28 used a pho-
toelastic stress analysis to examine the
stress patterns under dentures. The
authors suggested that a flat occlu-
sal scheme transferred slightly lower
forces to the residual ridge compared
to other cuspal forms. Chowdhary
et al17 investigated the stress gener-
ated beneath complete dentures us-
ing denture teeth with different cus-
pal angulations. These authors used
finite element analysis and found
greater magnitudes of stresses in
33-degree and 20-degree cusp teeth,
respectively, whereas 0-degree teeth
showed the least. Swoope and Kydd29
used electronic strain gauges to study
the effect of different cusp forms and
occlusal surface areas on complete
denture base deformation. The au-
thors suggested that angle reduction
of posterior teeth cusps decreased
the deformation of complete denture
bases, which, in turn, reduced the
horizontal stress to residual ridges.
These studies,17,29 however, did not
clearly demonstrate the amount and
pattern of pressure distribution be-
neath denture bases because finite
element analysis is a mathematical
technique for finding approximate so-
lutions, and strain gauges are suitable
for specific site measurements.
Arksornnukit et al
February 2011
Criteria for measurement of pres-
sure beneath denture bases have been
offered by several investigators.30-32
Many methods and measuring devic-
es have been developed. Strain gauges
and pressure transducers are 2 of the
most common pressure-recording
devices. However, these 2 devices are
only suitable for measuring pressure
at specific sites. A pressure-sensitive
sheet (Fuji Prescale Film; Fuji Photo
Film Co, Ltd, Tokyo, Japan) has been
used as a pressure-detecting device
for measuring occlusal pressure, oc-
clusal force, and occlusal contact
areas.33,34 Recently, pressure-sensitive
sheets were used for pressure mea-
surement under denture bases to
evaluate pressure transmission and
distribution. Pressure distribution un-
der impact load was reported to vary
due to the differences in denture tooth
materials.35 Pressure-sensitive sheets
are useful in pressure measurement
because they are easy to use for the
evaluation of large pressure ranges
and areas.33,34
The purpose of this study was to
examine pressure transmission and
distribution under denture bases us-
ing denture teeth made of different
materials with different cuspal an-
gulations under an impact load, and
Table I. Artificial denture teeth used
Type
Acrylic resin
0 degree
20 degree
33 degree
Microfilled
composite resin
0 degree
33 degree
Ceramic
0 degree
20 degree
35 degree
* Teeth were prepared from 20-degree denture teeth after impact test.
Arksornnukit et al
to determine whether there were any
significant interactions between ma-
terials and cuspal angulations with
respect to the pressure transferred.
The null hypotheses of the present
study were that there would be no dif-
ferences in pressure transmission and
distribution using denture teeth with
different materials and cuspal angu-
lations, and no interactions between
materials and cuspal angulations with
respect to pressure transferred.
MATERIAL AND METHODS
Eighty pairs of maxillary and man-
dibular right and left first molars of 3
different types (acrylic resin, micro-
filled composite resin, and ceramic)
and 4 different cuspal angulations
(0, 20, 33, and 35 degree) of denture
teeth were examined in this study. The
combinations of materials and angula-
tions are listed in Table I. The 20-de-
gree acrylic resin and ceramic denture
teeth were flattened to 0 degrees after
completing the impact test and were
described as the 0-degree acrylic resin
and 0-degree ceramic denture teeth
groups, respectively.
A simplified model of a tooth
specimen was made of a denture
tooth in an acrylic resin denture
Brand Name Mold
Bioace Resin (modified)* M30
Bioace Resin M30
Resin Kyushi M30
Endura Posterior M30
Endura Posterior M30
Bioace Ceramic (modified)* M30
Bioace Ceramic M30
Bioace Ceramic M30
129
base. The denture bases were made
by using putty-type silicone impres-
sion material (Provil Novo; Heraeus
Kulzer GmbH, Hanau, Germany) as
a mold. Melted wax was poured into
the mold and each denture tooth was
lowered into the wax using a surveyor
(Ney Surveyor Parallelometer System;
Dentsply Ceramco, Burlington, NJ)
to ensure that the occlusal surface
was parallel to the base. All speci-
mens were then invested in denture
flasks (Hanau; Water Pik, Inc, Ft. Col-
lins, Colo), followed by conventional
packing procedures36 using heat-po-
lymerizing acrylic resin (Lucitone 199;
Dentsply Trubyte, York, Pa). Long po-
lymerizing cycles were used for acrylic
resin packing procedures. The tem-
perature was slowly raised from room
temperature to 74°C and held for 9
hours. After completion of polymer-
izing cycles, the flasks were allowed
to cool to room temperature before
deflasking. All specimens were then
removed from the denture flasks and
any flash was removed with a carbide
bur (Abbott-Robinson HP Burs; Buf-
falo Dental Mfg Co, Syosset, NY). The
denture base of each tooth specimen
was shaped to a size of 15 x 15 mm,
with a thickness of 3 mm. The bases
of the specimens were polished with
Manufacturer
—
Shofu, Inc,
Kyoto, Japan
Shofu, Inc
Shofu, Inc
Shofu, Inc
—
Shofu, Inc
Shofu, Inc
130
1 Maxillary and mandibular denture tooth specimens.
an automatic polishing machine (DPS
3200; Imptech, Boksburg, South Afri-
ca) under a slow speed with constant
water irrigation. The final polishing
steps for all specimens were complet-
ed by using 0.05-µm-particle-sized
aluminum oxide slurry (Leco Corp,
St. Joseph, Mich).
The same methods for prepar-
ing each tooth specimen were used
for both maxillary and mandibular
denture teeth. After the impact test,
the occlusal surfaces of the 20-de-
gree acrylic resin denture teeth were
carefully flattened and polished with
up to 1200-grit silicon carbide pa-
per (Silicon Carbide Grinding paper;
Buehler, Düsseldorf, Germany) under
water irrigation. For the 20-degree
ceramic denture teeth, a polishing kit
(Soft Diamonds Grinding and Buffing
Wheels; Asami Tanaka Dental, Fried-
richsdorf, Germany) was used for the
final polishing procedure. Grinding
and polishing procedures were per-
formed on these denture teeth until
flat occlusal surfaces were achieved.
After the teeth were flattened, there
were still some grooves on the occlu-
sal tables. The surveyor was used to
ensure that the flat occlusal surfaces
were parallel to the base. These pol-
ished specimens were the 0-degree
denture teeth groups.
After preparing all specimens,
each pair of maxillary and mandibular
denture teeth was arranged in a Class
I occlusal relationship on the impact
load testing apparatus. The occlu-
The Journal of Prosthetic Dentistry
sion between maxillary and man-
dibular denture teeth was evaluated
by using articulating paper (Red/
Blue articulating film; Ardent Intl,
Inc, Ossining, NY). Occlusal adjust-
ment was performed by the selective
grinding procedure to obtain proper
centric occlusion. Final polishing
procedures for the different types
of denture teeth were performed ac-
cording to the material specification
for each type of denture tooth.36 The
occlusal contact areas were measured
using pressure-sensitive sheets to en-
sure that uniform occlusal contact
areas were achieved for all groups.
The maxillary and mandibular tooth
specimens are shown in Figure 1.
Three types of pressure-sensitive
sheets (Fuji Prescale Film, LW, LLW,
and LLLW; Fuji Photo Film Co, Ltd,
Tokyo, Japan) were used to detect
pressure transmission and distribu-
tion under denture bases in the pres-
ent study. The measuring ranges of
the 3 pressure-sensitive sheets, LW,
LLW, and LLLW, are between 2.5 and
10.0 MPa, 0.5 and 2.5 MPa, and
0.2 and 0.6 MPa, respectively. The
structure of the pressure-sensitive
sheet consists of microencapsulated
color-forming and color-developing
materials. When contact pressure is
applied to the sheet, a red-colored
impression is formed in various den-
sities according to the amount of
pressure and pressure distribution.
The maxillary denture tooth was at-
tached to a weight and the pressure
Volume 105 Issue 2
was applied by dropping the weight
freely onto the antagonist mandibu-
lar denture tooth specimen, with the
sheet placed underneath to measure
average pressure, maximum pressure,
and pressure transmission areas. The
LLW sheet type was primarily used for
pressure measurements. When aver-
age or maximum pressure was found
to be above or below its measuring
ranges, LW or LLLW sheets were used,
respectively.
All pressure-sensitive sheets ac-
quired from the tests were analyzed
with digital analysis software (Fuji-
Film Pressure Distribution Mapping
System FPD-8010E, v. 1.1; Fuji Photo
Film Co, Ltd). According to the man-
ufacturer, the accuracy of a pressure-
sensitive sheet is ±10%. The authors
of a previous study37 suggested that
for the greatest accuracy and reliabili-
ty, pressure-sensitive sheets should be
analyzed within 8 hours of exposure
to pressure. In the present study, pres-
sure-sensitive sheets were analyzed
immediately after testing to achieve
maximum accuracy and reliability.
The impact drop test used in the
present study was modified from that
used in the previous study by Phunt-
hikaphadr et al.35 A study conducted
by Miyaura et al33 revealed that the
average occlusal force for a complete
denture patient was around 50 N us-
ing pressure-sensitive sheets as mea-
suring devices. Therefore, a load of
50 N was used in the present study.
The maxillary denture tooth that was
attached to the weight was freely
dropped over a distance of 5 mm to-
wards the mandibular denture tooth.
A small piece of the LW pressure-sen-
sitive sheet was placed at the occlu-
sal contact interface to measure and
confirm the occlusal force of 50 N.
The impact load testing apparatus is
shown in Figure 2.
Statistical software (SPSS v. 17.0;
SPSS, Inc, Chicago, Ill) was used for
statistical analysis. To assess signifi-
cant interactions between denture
tooth materials and cusp angula-
tions, the 20-degree denture teeth
groups were first omitted, and a
Arksornnukit et al
February 2011
2 Impact load testing apparatus. Maxillary denture
tooth was freely dropped from height of 5 mm to create
50-N load at occlusal surfaces.
2-way ANOVA was used to determine
interactions for 3 materials x 2 angu-
lations (0, 33/35). The interaction
and any significant main effects were
tested with 1-way ANOVA (α=.05) to
examine the joint effect of the mate-
rial and cusp angulation on pressure
transmission. Two separate 1-way
ANOVAs were then performed on
the acrylic resin and ceramic denture
teeth groups with 20-degree denture
teeth. Tukey’s Honestly Significant
Difference (HSD) test was used for
post hoc multiple comparison. The
robust tests of equality of means and
Tamhane’s post hoc test were used
when equal variances could not be as-
sumed.
RESULTS
Representative pressure-sensitive
sheets (LLW type) obtained from dif-
ferent types of denture teeth with dif-
ferent cuspal angulations are shown
in Figure 3. Pressure-sensitive sheets
(LLW type) acquired from the im-
pact test showed some similarities
as well as variations among groups.
Different amounts and patterns of
pressure distribution were demon-
Arksornnukit et al
strated (Fig. 3). Zero-degree denture
teeth from all denture tooth material
groups showed lower pressure trans-
mission compared to cusped denture
teeth. High and localized pressure
transmission was observed in the 20-
and 35-degree ceramic denture teeth
groups.
Two-way ANOVA (Table II) indi-
cated significant differences among
materials (P<.001) and among cuspal
angulations (P<.001), with a signifi-
cant interaction between these 2 fac-
tors (P<.001) with respect to average
pressure transmission. A statistically
significant interaction between mate-
rials and angulations was also found
in maximum pressure transferred
(P=.007), with significant differences
among materials (P=.041) and cus-
pal angulations (P<.001). As for the
pressure transmission area, signifi-
cant differences were observed within
the material (P<.001) and angulation
(P<.001) factors; however, no signifi-
cant interaction between these 2 fac-
tors was shown (P=.104).
One-way ANOVA and post hoc
multiple comparison tests were then
performed to determine how mate-
rials and angulations jointly affect
131
the average and maximum pressure
transmission. One-way ANOVA re-
vealed significant differences in aver-
age pressure (P<.001) and maximum
pressure transmission (P<.001) with
respect to different materials and
cuspal angulations. Means of average
and maximum pressure transmission
and multiple post hoc comparisons
are shown in Table III. Thirty-five-de-
gree ceramic denture teeth presented
the significantly highest average pres-
sure, jointly followed by 33-degree
acrylic resin and microfilled compos-
ite resin denture teeth, and 0-degree
denture teeth presented the lowest
average pressure. No statistically sig-
nificant difference with respect to
average pressure transmission was
found between different types of
tooth materials on 0-degree denture
teeth (Table III). As for maximum
pressure transmission of all 3 denture
tooth materials, 33- and 35-degree
showed significantly higher maximum
pressure compared to 0-degree den-
ture teeth. No significant differences
were observed for 0-degree denture
teeth (Table III).
Two 1-way ANOVAs were per-
formed on the acrylic resin and ceram-
ic denture teeth groups with 20-de-
gree denture teeth. Means of average
pressure, maximum pressure, and
pressure transmission area for all an-
gulations of acrylic resin and ceramic
denture teeth are shown in Table IV.
There were significant differences in
average pressure transmission in the
acrylic resin (P<.001) and ceramic
denture teeth (P<.001) groups with
respect to different cuspal angula-
tions. However, no statistically signif-
icant difference was found between
20-degree and 33-degree angulations
in the acrylic resin denture teeth
group (Table IV). Significant differ-
ences in maximum pressure transmis-
sion with respect to different cuspal
angulations were found in both the
acrylic resin (P<.001) and ceramic
(P<.001) denture teeth groups. Maxi-
mum pressure transmission observed
for denture teeth with greater cuspal
angulations was greater than that for
132 Volume 105 Issue 2

3 Representative pressure-sensitive sheets under denture bases obtained from all groups.

Table II. Two-way ANOVA for materials (A) and cusp angulations (B) on average pressure,
maximum pressure, and pressure transmission area (20-degree denture teeth groups omitted)

Sum of Mean
Source df Squares Square F P

Average pressure
Materials (A) 2 0.236 0.118 78 <.001
Angulations (B) 1 3.413 3.413 2259 <.001
AxB 2 0.210 0.105 69 <.001
Error 54 0.082 0.002 — —

Maximum pressure
Materials (A) 2 2.00 1.00 3.4 .041
Angulations (B) 1 139 138.68 469 <.001
AxB 2 3.25 1.62 5.5 .007
Error 54 16 0.29 — —

Pressure transmission area

Materials (A) 2 3564 1782 13 <.001
Angulations (B) 1 23522 23522 169 <.001
AxB 2 657 328 2.35 0.104
Error 54 7533 139 — —

denture teeth with lower cuspal angu-
lations. However, no significant dif-
ferences were found between 20- and
33-degree angulations for acrylic res-
in and 20- and 35-degree angulations
for ceramic denture teeth groups.
The total denture base area calcu-
The Journal of Prosthetic Dentistry
lated by the size of the denture base
specimen was 225 mm2 (15 x 15 mm).
The areas of colors developed on the
sheet represent the pressure transmis-
sion areas. Significant differences in
pressure transmission areas with re-
spect to different cuspal angulations
were found in the acrylic resin (F=26,
df=2, P<.001) and ceramic (F=20, df=2,
P<.001) denture teeth groups. Thirty-
three-degree acrylic resin denture teeth
exhibited significantly larger pressure
transmission areas than 20- and 0-de-
gree groups. As for the ceramic den-
Arksornnukit et al
February 2011 133

Table III. Means of average and maximum pressure transmission (MPa) and Tam-
hane analysis (20-degree denture teeth groups omitted)

Denture Teeth Mean (SD) in MPa Tamhane Analysis

Average pressure transmission

0-degree acrylic resin 0.36 (0.01) A
0-degree microfilled composite resin 0.37 (0.02) A
0-degree ceramic 0.37 (0.01) A
33-degree acrylic resin 0.76 (0.04) B
33-degree microfilled composite resin 0.76 (0.05) B
35-degree ceramic 1.01 (0.06) C

Maximum pressure transmission

0-degree acrylic resin 1.71 (0.16) A
0-degree microfilled composite resin 1.63 (0.11) A
0-degree ceramic 1.57 (0.06) A
33-degree acrylic resin 4.28 (0.63) B
33-degree microfilled composite resin 4.50 (0.86) B
35-degree ceramic 5.25 (0.77) B

Groups with same uppercase letters were not significantly different at P<.05.

Table IV. Means of average pressure, maximum pressure, and pressure transmission area for all angula-
tions of acrylic resin and ceramic denture teeth groups

Average Pressure Maximum Pressure Pressure Transmission area

Denture Teeth Mean (SD) in MPa Mean (SD) in MPa Mean (SD) in mm2

Acrylic resin
0 degree 0.36 (0.01)a 1.71 (0.16)a 78.60 (14.02)a
20 degree 0.74 (0.08)b 4.01 (0.49)b 86.00 (7.18)a
33 degree 0.76 (0.04)b 4.28 (0.63)b 112.10 (10.73)b

Ceramic
0 degree 0.37 (0.01)a 1.57 (0.06)a 68.60 (11.35)a
20 degree 0.87 (0.10)b 4.98 (0.60)b 86.00 (10.62)b
35 degree 1.01 (0.06)c 5.25 (0.77)b 105.10 (15.81)c

Groups with same superscript lowercase letters were not significantly different at P<.05.

ture teeth group, denture teeth with
greater cuspal angulations presented
significantly larger pressure trans-
mission areas compared to denture
teeth with lower cuspal angulations
(Table IV).
DISCUSSION
Differences in pressure transmis-
Arksornnukit et al
sion and distribution using denture
teeth made of different materials with
different cuspal angulations were
observed in this study; in addition,
interactions were observed between
tooth materials and angulations with
respect to the pressure transferred.
Therefore, the two null hypotheses
were rejected.
Denture teeth used in the present
study were selected from the same
mold and manufacturer to minimize
the effect of size and shape of the
specimens. In addition, all denture
base resin fabrication was controlled
to be the same in every specimen;
thus, the results were compared only
with respect to the different artificial
denture teeth materials. All denture
teeth with different angulations were
134
selected from the same manufacturer,
except for the 0-degree acrylic resin
and 0-degree ceramic denture teeth,
which were modified by the authors
and manufactured according to in-
formation presented in Table I. Both
20-degree acrylic resin and ceramic
denture teeth were selected, flat-
tened, and used as the 0-degree teeth
groups as they were considered sim-
pler to manipulate than their 33- and
35-degree counterparts.
The simplified models of maxillary
and mandibular posterior denture
teeth were fabricated with Angle’s
Class I occlusal relationship in an at-
tempt to simulate a normal occlusal
relationship. Minor occlusal adjust-
ments were made to achieve proper
occlusion between maxillary and
mandibular denture teeth, and this
procedure is considered to be similar
to clinical procedures. The same type
(LLW) of pressure-sensitive sheet was
used, primarily to determine the dis-
tribution of pressure; therefore, the
pattern of pressure distribution was
clearly demonstrated in the present
study (Fig. 3).
Both denture tooth materials and
cuspal angulations had a significant
influence on average and maximum
pressure transmission, as statistically
significant interactions were observed
in the present study (Table II). Thirty-
three-degree acrylic resin and micro-
filled composite resin teeth presented
about twice as much of the average
pressure transferred compared to
0-degree denture teeth (Table III). In
addition, 35-degree ceramic denture
teeth displayed the significantly high-
est average pressure in the test groups
(Table III and IV). These results sug-
gest that selecting proper denture
tooth materials and angulations
should be considered when pressure
transmission under denture bases is
a concern, such as when treating pa-
tients with flat residual ridges.
The authors of a previous study35
discussed the role of the modulus of
elasticity of denture tooth materials
on pressure transmission. Denture
teeth with low elastic modulus may
The Journal of Prosthetic Dentistry
flex and absorb impact force and
transfer less pressure to underlying
structures. However, results from the
present study showed that no signifi-
cant differences were found in 0-de-
gree denture teeth made of 3 different
denture tooth materials (Table III).
This finding revealed that 0-degree
angulation may nullify the effect of
the modulus of elasticity; this was
confirmed by both the average and
maximum pressure transmission re-
sults (Table III).
When comparing 20-degree acryl-
ic resin and ceramic denture teeth with
teeth with other cuspal angulations,
interesting results were observed.
Twenty-degree acrylic resin denture
teeth showed no significant differenc-
es in average and maximum pressure
compared to 33-degree acrylic resin
teeth (Table IV). However, a signifi-
cantly smaller pressure transmission
area was observed for the 20-degree
teeth (86.0 mm2) compared to the
33-degree teeth (112.1 mm2). These
results suggest that 20-degree may
be preferable to 33-degree acrylic
resin teeth, as the smaller angula-
tion resulted in smaller pressure ar-
eas transferred to underlying denture
bases. As for ceramic denture teeth,
20-degree teeth showed significantly
lower average pressure than 35-de-
gree teeth, while no significant differ-
ence was found in maximum pressure
compared to 35-degree teeth. Zero-
degree ceramic teeth demonstrated
significantly lowest average and maxi-
mum pressure and smallest pressure
transmission areas compared to 20-
and 35-degree teeth. Zero-degree or
20-degree ceramic teeth appear to be
the better choice compared to 35-de-
gree teeth when ceramic denture teeth
are indicated, as they showed better
results in the measured parameters.
The results of the present study
were in agreement with those of
Chowdhary et al,17 who used the finite
element analysis method to examine
stress generated beneath complete
dentures using denture teeth with dif-
ferent cuspal angulations. The find-
ings of the present study support the
Volume 105 Issue 2
concept that using denture teeth with
lower or flatter cuspal angulations
might be a desirable option because
they transfer less force and pressure
to the underlying structures. Mono-
plane denture teeth, which provide
less force and better pressure distri-
bution, should be used in highly at-
rophied alveolar ridges as they induce
lower lateral forces than anatomic
teeth.28,29
Most clinicians choose cusped
denture teeth for balanced occlusal
schemes in complete dentures, as
Boucher suggested that it is easier to
acquire bilateral balanced occlusion
compared to cuspless teeth.22 Results
from the present study suggest that
choosing 33-degree acrylic resin or
33-degree microfilled composite resin
denture teeth for bilateral balanced
occlusion is better, because average
pressure transmission was reduced
when these materials and angulations
were used (Table III). With respect to
teeth made of acrylic resin, 20-de-
gree angulations seem to be a better
choice as compared to 33-degree an-
gulations, as these cuspal angulations
resulted in smaller pressure transmis-
sion areas beneath the denture bases
(Table IV). As for the monoplane oc-
clusion concept, 0-degree denture
teeth made of any of the 3 materials
appear to be acceptable options, as
there were no statistical differences in
average and maximum pressure trans-
mission found in the present study
(Table III).
Pressure is defined as force per
unit area. Matsuo et al9 suggested
that alveolar bone remodeling is ini-
tiated when a pressure of 27 to 68
g/cm2 is exerted on fibroblast cells.
Berg10 also reported that to keep
blood circulation normal, continu-
ous mechanical pressure higher than
1.3 kPa should not be transferred to
the denture-supporting tissues. The
average and maximum pressure trans-
mission observed in the present study
ranged from 0.36 to 5.25 MPa (Ta-
bles III and IV), which was higher than
the pressures described in the previ-
ously mentioned studies. However,
Arksornnukit et al
February 2011
the size of the denture base specimen
in the present study was only 225
mm2; therefore, it had a limited area
to absorb the pressure. Maximum ex-
tension of the denture bases within
anatomical and physiological limits
is strongly recommended to increase
the supporting areas and minimize
the pressure to the underlying bone
beneath denture bases.
The present study evaluated pres-
sure transmission and distribution us-
ing simplified models under vertical
impact loads. A limitation was that
pressures beneath denture bases were
investigated using only one direction
of force. The simplified model used in
this study consisted of only one den-
ture tooth in a small square resin block
with no periosteum or bone beneath
the denture base. The magnitude of
pressure transmission might be modi-
fied in the clinical setting as dentures
have more denture base area com-
pared to the simplified model used in
the present study. Pressure transmis-
sion and distribution under maxillary
and mandibular complete dentures
may also be different due to denture
configuration, for example, the load-
sharing function of the palate in max-
illary dentures. Moreover, the 0-de-
gree denture teeth of the acrylic and
ceramic groups were modified from
their 20-degree counterparts. The
occlusal surfaces of these 0-degree
denture teeth groups may not be the
same as other manufactured mono-
plane denture teeth; therefore, pres-
sure transmission beneath denture
bases may be slightly different. How-
ever, this in vitro study has shown
that under the same controlled condi-
tions, denture teeth with smaller cus-
pal angulations transferred less force
through the denture base and, there-
fore, may be considered preferable for
compromised patients. Further stud-
ies with conditions that more closely
simulate the oral environment, as well
as clinical studies, would be useful for
evaluating and understanding pres-
sure beneath maxillary and mandibu-
lar dentures.
Arksornnukit et al
CONCLUSIONS
Within the limitations of the pres-
ent study, the following conclusions
were drawn.
1.  Signif icant  interactions  were
observed between denture tooth ma-
terials and cuspal angulations with
respect to average pressure (P<.001)
and maximum pressure (P=.007)
transmission.
2. Zero-degree denture teeth showed
significantly lower average and maxi-
mum pressure transmission compared
to 33- and 35-degree denture teeth for
all 3 denture tooth materials evaluated
(P<.001).
3. Denture teeth with greater cuspal
angulations demonstrated significantly
higher average pressure transmission
for all ceramic denture teeth groups
(P<.05).
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Corresponding author:
Dr Mansuang Arksornnukit
Chulalongkorn University
Bangkok, 10300
THAILAND
Fax: +662 218 8534
E-mail: mansuang@yahoo.com
Acknowledgments
The authors thank Shofu, Inc. Kyoto, Japan,
for their generous donation of the artificial
denture teeth used in the study. The authors
also extend special thanks to Mr. Daniel Gill
for his invaluable help with the final language
editing.

Copyright © 2010 by the Editorial Council for

The Journal of Prosthetic Dentistry.

Noteworthy Abstracts of the Current Literature

Mandibular overdentures retained by two implants: 10-year results from a crossover
clinical trial comparing ball-socket and bar-clip attachments

Cune M, Burgers M, van Kampen F, de Putter C, van der Bilt A.

Int J Prosthodont 2010;23:310-7.

Purpose. The aim of this study was to evaluate patient satisfaction and clinical and prosthetic outcomes of two-im-
plant mandibular overdenture treatment with different attachment types after 10 years of function.

Materials and Methods. In a crossover clinical trial, 18 edentulous subjects with complaints regarding their man-
dibular dentures received two implants and a new denture with magnet, ball-socket, or bar-clip attachments that
were applied in a random order. At the end of the experiment, the attachment type of their choosing was fitted in the
overdenture. After 10 years, 7 subjects with a ball-socket and 7 subjects with a bar-clip attachment were available
for evaluation. The same questionnaire from 10 years before was completed, and subjects were asked to express their
overall appreciation of their dentures on a visual analog scale (VAS). Six scales of denture complaints were construct-
ed. Mean scale and VAS scores between initial evaluation and after 10 years were compared. In addition, marginal
probing depths, Bleeding Index, and radiographic marginal bone loss were assessed.

Results. There was no marked difference in satisfaction between subjects with ball-socket– and bar-clip–retained
two-implant mandibular overdentures at initial evaluation and after 10 years of function.

Conclusion. Patients’ appreciation of their implant-retained denture was and remained high over time. Clinical pa-
rameters revealed healthy mucosal conditions and stable marginal bone levels, determined radiographically. Probing
depths around implants provided with ball-socket attachments were slightly shallower than those with bar-clip attach-
ments after 10 years of function (P < .05).

Reprinted with permission of Quintessence Publishing.

The Journal of Prosthetic Dentistry Arksornnukit et al